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88,000 people enrolled for 2019, down from more than 108,000 in 2016. But 2019 enrollment was nearly 6 percent higher than the year before (as opposed to declining enrollment in most states that use HealthCare.gov).

Blue Cross Blue Shield of Mississippi has a strong presence in the Mississippi individual market, but they do not participate in the exchange. Magnolia/Ambetter offers plans statewide in the Mississippi exchange, and became the only insurer offering exchange coverage after Humana exited at the end of 2017. But Molina joined the exchange in 19 counties for 2020, giving residents in those counties a choice of two health plans.

Molina joined the exchange for 2020; Ambetter’s average rates decreased by about 1%

Magnolia/Ambetter offers plans statewide in the Mississippi exchange in 2020. According to the federal rate review site, Ambetter decreased their average prices by 1.1 percent for 2020.

Although the entry of a new insurer is welcome news in terms of competition, the effect on premium subsidies (which are used by 94 percent of the state’s exchange enrollees in 2020) depends on whether the new insurer has lower prices than the existing insurer and whether it introduces a new benchmark plan. Enrollees in those 19 counties needed to carefully compare their options for 2020 to see which insurer offered the best value.

2019 rates and plans

Ambetter/Magnolia was the only insurer offering plans in Mississippi’s exchange for 2019. Average premiums for Ambetter plans were mostly unchanged for 2019, with an average rate increase of just 0.27 percent.
Almost all of Mississippi’s exchange enrollees — 98 percent — received premium subsidies in 2019 (that’s the highest rate in the nation; the nationwide average was 87 percent; this is unsurprising, since subsidy eligibility is based on income, and Mississippi has the lowest average household income in the US). Premium subsidies are based on the cost of the benchmark plan, and average benchmark premiums in Mississippi were also virtually unchanged in 2019, with an average increase of 0 percent. So average subsidies were very similar to the amounts people got for 2018. The percentage of income that people have to pay for the benchmark plan, after subsidies, was a little higher for 2019 than it was in 2018, but that was at least partially offset by the slight increase in the cost of the average benchmark plan.
Ambetter continued to add the cost of cost-sharing reductions (CSR) to premiums for plans at all metal levels (ie, a “broad load”) in 2019, rather than just to silver plan premiums. This was confirmed in Ambetter’s actuarial memo for 2019.

As discussed below, Mississippi was one of just five states (Colorado, Indiana, West Virginia, and Delaware) where the cost of CSR was added to premiums at all metal levels for 2018, after the Trump Administration cut off federal funding for CSR. As of 2019, Delaware and Colorado switched to having insurers add the cost of CSR only to silver plans, but Mississippi, Indiana, and West Virginia continued to have insurers spread the cost of CSR across all plans. Mississippi Commissioner Mike Cheney favors the broad load approach, saying that it’s fairer for everyone.

But when the cost of CSR is added to silver plan premiums, it results in much larger premium subsidies for anyone who gets a subsidy. And people who don’t get a subsidy can either enroll in a bronze or gold plan (without the cost of CSR added to the premiums), or, if off-exchange-only plans are available, those can also be offered without the cost of CSR added in, even at the silver plan level. Adding the cost of CSR to only silver plan premiums is considered the approach that’s most beneficial to the most people.

Interestingly, Ambetter also noted that they did not add to their premiums for 2019 or for 2020 to account for the fact that the Trump Administration has made it easier for healthy people to exit the individual market and enroll instead in longer short-term plans (and for the self-employed, association health plans). Mississippi defaults to the federal rules for short-term plans, so short-term policies in the state are now available with initial terms of up to 364 days.

As has been the case in prior years, Blue Cross Blue Shield of Mississippi is continuing to offer their plans only outside the exchange for 2020. Their average premiums increased by about 2.3 percent for 2020, but premium subsidies are not available to offset the cost of BCBSMS plans: They’re only sold outside the exchange, and subsidies can only be used for plans purchased in the exchange.

Mississippi exchange enrollment: 2014-2020

Mississippi exchange enrollment grew from 2014 through 2016, then dropped sharply in 2017. It dropped again in 2018, but has increased since then. The percentage increase in enrollment for 2020 was the largest in the country. Here’s a summary of how enrollment has changed over the years in Mississippi’s exchange:

2014: 61,494 people enrolled (most enrolled in a plan from Humana, which was the only insurer in all but four counties)

2016: 108,672 people enrolled (effectuated enrollment stood at 77,747 by March 31, 2016 — that’s an attrition rate of 28 percent, which was more than double the national average rate of attrition during the first quarter).

2017: 88,483 people enrolled. President Trump took office less than two weeks before the end of open enrollment that year, and immediately eliminated an advertising campaign that had been designed to direct people to HealthCare.gov to enroll in coverage. Across all states that use HealthCare.gov, enrollment dropped by about 5 percent in 2017, but in Mississippi, it dropped by almost 19 percent.

2019: 88,542 people enrolled. In most states that use HealthCare.gov, enrollment continued to decline in 2019, but that was not the case in Mississippi. Among the 39 states that use HealthCare.gov, only six saw their enrollment grow in 2019, and only Oklahoma had a higher percentage increase in enrollment than Mississippi.

2020: 98,892 people enrolled. This was nearly a 12 percent increase over 2019’s enrollment, which was the largest percentage increase in the country. That could be partially due to the fact that enrollment had dropped so precipitously in 2017 (more so than the rest of the country), and also partially due to a new insurer joining the exchange in some areas of the state.

Insurer participation in Mississippi’s exchange: 2014-2020

In 2011 and 2012 — back when Mississippi was considering creating its own State-run exchange — Blue Cross Blue Shield of Mississippi (which had more than 80 percent of the market share in Mississippi) had told Insurance Commissioner Mike Chaney that they would participate in the exchange. But due to conflicts among the state’s leadership, HHS rejected Mississippi’s exchange application (more details below), and at that point, BCBS of Mississippi pulled out.

That left Humana and Magnolia Health Plan as the only two carriers for 2014. But leading up to the federally-run exchange’s fall 2013 debut, Mississippi had a problem. The two carriers had selected the counties in which they wanted to operate, and 36 of the state’s 82 counties had no participating carriers at all. Humana ultimately decided to go ahead and offer coverage state-wide in 2014, but only four of the state’s counties had plans available from both carriers in 2014.

In 2014 and 2015, plans were available in Mississippi’s exchange from Humana and Magnolia Health Plan (Ambetter/Centene).

For 2016, UnitedHealthcare joined them, bringing the total number of insurers on the individual exchange to three. United was the only carrier in the Mississippi exchange that offered coverage in all 82 counties in the state in 2016. Residents in every county in the state had at least two carriers from which to choose that year, and 32 counties had plans available from all three carriers.

But for 2017, United left the state (as was the case in most states where United had been offering exchange plans), and Mississippi’s exchange was back to just Humana and Magnolia (Mississippi Insurance Commissioner Mike Chaney had reported in August 2016 that a third health insurer had proposed joining the exchange state-wide, but had been rejected by HHS due to “lack of an adequate network and specialists in each county”).

Although Humana exited the exchanges in several states at the end of 2016, they stayed in Mississippi for 2017. There were 32 counties where both insurers offered plans that year, and 50 counties where the only carrier offering plans in the exchange was Magnolia (Magnolia had expanded to offer coverage statewide as of 2017).

Rate changes in Mississippi’s exchange in previous years

2014:

For 2014, individual market health insurance premiums were essentially actuaries’ best guesses, as there was no market experience on which to base the rates (prior to 2014, individual market coverage was medically underwritten, so there was a seismic shift in 2014 in terms of claims experience). In 2014, Mississippi’s pre-subsidy average premium was $438/month — the fifth-highest among the 36 states that used Healthcare.gov.

2015: Average decrease of 19%

In 2015, according to an analysis published by The Commonwealth Fund, average premiums in Mississippi were 19 percent lower than they had been in 2014. The weighted analysis looked at premium amounts, differences in premiums between urban/suburban/rural areas within states, and insurer participation. A similar analysis from PricewaterhouseCoopers found an average rate decrease of 9.3 percent from 2014 to 2015 — still a significant rate decrease, but not as substantial as the Commonwealth Fund’s result.

Magnolia Health/Ambetter: average decrease of 2.9 percent (18,000 enrollees as of November 1, 2015)

Humana: average decrease of 0.2 percent (16,915 enrollees as of November 1)

UnitedHealthCare: average increase of 6.6 percent (26,000 enrollees as of November 1)

Once all of the plan selections for 2016 had been finalized, 90 percent of Mississippi exchange enrollees qualified for premium subsidies. Their average pre-subsidy premium was $388 per month (a little lower than the $396/month average across all states that use Healthcare.gov), and their average after-subsidy premium was $91/month (the average after-subsidy premium across all Healthcare.gov states was $106/month that year).

Statewide, the average benchmark (second-lowest-cost Silver) plan premium was 8.2 percent less expensive in 2016 than it was in 2015. Out of the 37 states that used Healthcare.gov in 2015, only four had lower average benchmark premiums in 2016, and Mississippi was one of them. The benchmark plan isn’t necessarily the same plan from one year to the next, so the changes in benchmark premiums don’t really tell us much about how premiums on specific plans are changing. But premium subsidies are tied to benchmark premiums, so average subsidies in Mississippi were smaller in 2016 than they were in 2015.

Outside the exchange, Blue Cross Blue Shield of Mississippi requested an average rate increase of more than 25 percent, but their final approved rate increase was 16.5 percent. Also off-exchange, Enterprise Live and Freedom Life both ended up with average rate increases of 9.9 percent. UnitedHealthcare was also listed in the rate review tool with a rate increase of 21.1 percent, but only for off-exchange plans that have a total of 513 enrollees.

2017: Average increase of about 16%

The following rate increases were proposed and approved for the Mississippi exchange in 2017 (rate increases are calculated before premium subsidies are applied):

Outside of the exchange, Blue Cross Blue Shield of Mississippi had an average rate increase of 16.12 percent for 2017. At ACA Signups, Charles Gaba calculated an average rate increase of 15.82 percent for the two exchange carriers, which is very similar to the rate hike for BCBSMS off-exchange plans.2018: Average increase of 47.3% (Magnolia/Ambetter was the only exchange insurer in 2018)

For 2018, Magnolia/Ambetter initially proposed average rate increases of 18 percent for their standard individual market plans, and 21.4 percent for their plans that include adult dental and vision coverage. The rate filing was heavily redacted, but it did note that the proposed rates were based on the assumption that the federal government would continue to fund cost-sharing reductions (CSR), and that larger premium increases would be necessary if CSR funding were to end.

Ultimately, the Trump administration did eliminate federal funding for CSR in October 2017, but Ambetter/Magnolia had already filed revised rates over the summer with the assumption that CSR funding would end. The revised rate proposal, which was approved by regulators, called for an average increase of 47.3 percent — more than two and a half times as large as the originally proposed increase.

The dramatic increase in the revised rates is because CSR is a larger expense in Mississippi than it is in other states. 86 percent of Mississippi exchange enrollees were receiving cost-sharing reductions at that point — the highest percentage in the nation, and well above the national average of 53 percent. Eligible enrollees have continued to receive CSR benefits, but the federal government is no longer reimbursing insurers for providing that benefit. So insurers in nearly every state added the cost of CSR to their premiums starting in 2018. In most states, the cost of CSR was added only to silver plans, which is beneficial for most enrollees, since premium subsidies are based on the cost of a silver plan, and larger silver plan premiums mean larger subsidies.

To clarify, Blue Cross Blue Shield of Mississippi does not add the cost of CSR to their plans, since they don’t incur any costs for CSR because their plans are not available on the exchange. Magnolia’s ACA-compliant plans include the cost of CSR in the premiums regardless of whether they’re sold on or off-exchange.

Mississippi’s Insurance Commissioner, Mike Chaney, noted in August 2017 that he didn’t think that CSR funding would continue, and that ultimately ended up being a prescient call, as CSR funding was eliminated two months later. Chaney’s office had initially directed Magnolia/Ambetter to file rates based on the assumption that cost-sharing reduction funding would continue, but noted that they’d be able to file new rates if CSR funding was not allocated (the revised were ultimately approved, based on the assumption that CSR funding would not continue).

King v. Burwell: Chaney had a plan in case SCOTUS ruling had been different

In June 2015, the Supreme Court ruled that subsidies are legal in every state, regardless of whether the exchange is run by the state or the federal government. That was great news for Mississippi residents, insurers, and healthcare providers; 98 percent of the people enrolled in private plans through the Mississippi exchange in 2019 were receiving premium subsidies.

The Mississippi Business Journal reported that Insurance Commissioner Mike Chaney had a contingency plan to protect subsidies for state residents if the Supreme Court had eliminated them. Rather than creating a state-run exchange, “it would entail funneling federal money through the existing Mississippi Comprehensive Health Insurance Risk Pool Association to private insurers.” But the Journal noted that the plan would have been contingent upon approval from the Governor, Lt. Governor, and the Speaker of the House (Chaney had worked to establish a state-run exchange back in 2011 – 2012, but was foiled by the Governor and the legislature).

Politico also reported that the state had a back-up plan, but they explained that Chaney wanted “Mississippi to use existing private health insurance exchanges to enroll people, qualifying for subsidies while avoiding the federal government’s technology.”

The Mississippi Comprehensive Health Insurance Risk Pool is the state-run high-risk pool that pre-dates the ACA. Private health insurance exchanges are not run by the government — rather, they’re set up by health insurance carriers, brokers and benefits managers to provide a platform for people to shop for coverage. Mississippi’s Insurance Department did not return phone calls to clear up the discrepancy, but it did appear that in early 2015, the state was working on a back-up plan that could have been put in place if the Supreme Court had eliminated subsidies. In many states, there were no such contingency plans, and enrollees would have had few options but to terminate their coverage if subsidies had been eliminated.

Enrollment assistance

The University of Mississippi Medical Center got the majority of the Navigator grants that were awarded by the federal government in August 2013 to fund enrollment efforts in Mississippi for 2014. Of $1.1 million that Mississippi received, $832,000 went to UMMC. Oak Hill Baptist Church got the remaining Navigator funding that year, but by 2015, Oak Hill had become the primary Navigator grant recipient in Mississippi, receiving $547,867 to assist with enrollment efforts for 2016 (another $415,224 was awarded to the University of Southern Mississippi in September 2015).

Navigator funding has been drastically reduced under the Trump Administration, however. In 2018, total Navigator grants in Mississippi came to less than $188,000. My Brother’s Keeper received $100,000 and Oak Hill got about $88,000. But navigator funding increased in Mississippi in 2019: My Brother’s Keeper got another $100,000, but Oak Hill got nearly $200,000.

Exchange creation battle in Mississippi

State Commissioner of Insurance Mike Chaney clashed with two governors as to what form a health insurance exchange should take in Mississippi. Chaney, former Gov. Phil Bryant, and former Gov. Haley Barbour are all Republicans and on record as opposing the Affordable Care Act. However, Chaney consistently maintained that the state would be better off running its own exchange.

Early exchange planning was carried out by the board of directors of the Risk Pool Association and an advisory board appointed by Chaney. The Risk Pool Association, the advisory board, and the insurance department continued working throughout 2012, and in November, Chaney notified the U.S. Department of Health and Human Services (HHS) that Mississippi intended to implement a state-run exchange. However, Bryant told HHS in December 2012 that Chaney had overstepped his authority.

It was also in 2012 that anti-ACA influences from outside Mississippi (including the Koch Brothers and the Cato Institute) began pressuring Cheney to give up his push for a state-run exchange. But One Mississippi, the state-run exchange that Cheney created, opened in October 2012, a year before the ACA-sanctioned exchanges nationwide. One Mississippi didn’t have any premium subsidies (those wouldn’t be available until the first ACA open enrollment period began in October 2013), but it did have coverage for sale. The task at that point switched to obtaining federal approval to have One Mississippi be the state’s official ACA exchange.

But ultimately, Governor Bryant’s opposition to the exchange was its downfall. In February 2013, HHS rejected Mississippi’s exchange blueprint, telling Chaney that it simply wouldn’t work without the Governor’s support. The exchange would have needed to work with the Mississippi Medicaid program — overseen by a Bryant appointee — and there were too many concerns that Bryant would be able to derail the exchange via funding or hiring decisions. The federal government said at the time that they “didn’t feel that [they] should get involved in a battle between two elected state officials.”

Mississippi was the only state whose exchange blueprint was rejected by the federal government, and in February 2013, One Mississippi shut down. The federal government ran the individual exchange in Mississippi from the start, but One Mississippi opened back up as the state-run SHOP exchange in the spring of 2014, offering health insurance options for small businesses. By 2018, however, Mississippi had opted to return to the federally-run exchange for small businesses. And even the federally-run small business exchange had switched to a direct-to-carrier enrollment model (instead of an enrollment portal on HealthCare.gov) by that point, as small business enrollment in the exchange had been quite low throughout most of the country.

Several factors constrain marketplace enrollment in the Magnolia State. Political opposition to the Affordable Care Act is very strong, many residents are distrustful of government assistance, and outreach efforts are limited. In a state with a 22 percent poverty rate, many people find premiums too expensive — even with subsidies factored in. And the Medicaid coverage gap is significant in Mississippi: Kaiser Family Foundation estimates that 100,000 Mississippi residents are in the coverage gap — ineligible for Medicaid (because the state has refused federal funding to expand Medicaid) and ineligible for subsidies in the exchange because their income is under the poverty level.